197609555-8-2-2023-31-AS-TCAS-CUBT38-20230802142154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609555
Report Date: 08/02/2023
Date Signed: 08/02/2023 02:23:28 PM

Document Has Been Signed on 08/02/2023 02:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	B AND B SENIOR VILLA		FACILITY NUMBER:	197609555
ADMINISTRATOR:	BAINGAN, GLADELYN		FACILITY TYPE:	740
ADDRESS:	23019 VISTA DELGADO		TELEPHONE:	(954) 200-0232
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	6	CENSUS: 6	DATE:	08/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Aileen Sangco Gladelyn Baingan		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection. LPA met with caregiver Aileen Sangco, who was informed the reason of the visit. Administrator Gladelyn Baingan was contacted, but was not available, but arrived at the conclusion of the inspection.

The current census is (6). Facility license/sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, daily menu, COVID signs and procedures was visibly posted. Administrator certificate current and valid September 2023.

A physical plant tour of the facility inside and outside was conducted with Aileen. The following common areas: dining, kitchen, family, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen: LPA observed a Licensing requirement of (7) day nonperishable, and (2) perishable, with (1) extra refrigerator stocked with food located in the garage. Food was labeled and properly stored in a healthy manner. Appliances were functional, clean, and in good repair. Chemicals, medication, household supplies, and knives, were secured and locked in kitchen cabinets and garage area. Dining/family: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms, with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. Rooms observed to have bedspreads, sheets, pillowcase, mattress pad, and blankets, and were in good repair. There were sufficient linens and towels observed. Bathrooms: There are (2); both were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 113.8 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards, passageways were free from obstruction, and gates were easily accessible. There was no swimming pools or other bodies of water. Smoke alarms and carbon monoxide detectors were tested and operating properly.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: B AND B SENIOR VILLA	FACILITY NUMBER: 197609555
	VISIT DATE: 08/02/2023

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Fire extinguisher fully charged. First aid kit furnished fully equipped. All exit doors have alarms; all were operating.

Record review: A complete record review of staff, residents, and medication records were conducted, and (2) staff did not have current first aid or CPR certificate. All residents and staff are fully vaccinated with booster shots.

TA citations issued, exit interview, and copy of report provided.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC809 (FAS) - (06/04)

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